Recurarization in the Post-anesthesia Care Unit One Hour After Sugammadex Administration: A Case Report

Postoperative recurarization has been a well-documented phenomenon since the advent of neuromuscular blockade drugs in clinical practice. Here, we present a case of recurarization after the use of rocuronium bromide in the post-anesthesia care unit (PACU), despite sugammadex administration and neuromuscular monitoring. A 68-year-old man with known psychiatric and obstructive pulmonary pathology underwent emergency surgery for abdominal evisceration correction. General anesthesia was induced with fentanyl, propofol, and rocuronium. At the end of the procedure, neuromuscular blockade was reversed with 200 mg of sugammadex under neuromuscular monitoring (train-of-four stimulation ratio >95%). The patient was transferred to the PACU 10 minutes after the end of the surgery. In the PACU, 4 mg of morphine were administered for analgesia. Fifty minutes later, peripheral oxygen saturation was 98% with a 2 L nasal cannula. The patient remained hemodynamically stable, but the Glasgow Coma Scale decreased to 3. Despite the administration of naloxone, no significant improvement in ventilation was observed. Arterial blood gas analysis revealed a high partial pressure of carbon dioxide at 82 mmHg, indicating severe respiratory insufficiency. Facial mask ventilation with a fraction of inspired oxygen of 100% was initiated. The patient recovered respiratory drive and consciousness in 15 seconds after 200 mg of sugammadex was administered. A cerebral tomography was performed to exclude central causes. After a prolonged stay in the PACU, the patient met the criteria for discharge to the ward. He died six days after surgery due to his underlying pathology and frailty.